GENERAL MEDICINE CASE DISCUSSION
August 2, 2023
General medicine case discussion
E LOG MEDICINE CASE
2/08/2023
This is is an online E log book to discuss our patient's deidentified health data shared after taking his/her/guardian's signed in formed consent.Here we discuss our individual patient's problems through series of inputs from available global online community of experts with an aim to solve those patient's clinical problems with collective current best evidence-based inputs.This e-log book also reflects my patient centered online learning protfolio and your valuable inputs on comment box is welcome.
Name : Katakam Sai Karthik
Roll no : 149
5th sem,2020 Batch
I have been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations and come up with a diagnosis and treatment plan.
72yr old male, unemployed and a resident of suryapet came to opd with
C/O
Pain in left knee since 1 month
Pain in right ankle since 3 weeks
Pain in left elbow since 3 weeks
Pain in multiple inter phalangeal joints since 1 week
History of presenting illness:
The patient was apparently asymptomatic 1 month ago,
After which he developed pain in left knee which was sudden in onset and pin pricking type of pain, it was non radiating with no aggrevating factors and relieves on medication.
He also complaints of pain in left flank region since 4 weeks
Later 3weeks ago he complained of same type of pain in right ankle and left elbow
Then 1 week ago he complained of same type of pain in multiple inter phalangeal joints in both hands
He complained of increased frequency of urination since 1 month
No history of fever, morning stiffness, sore throat.
Past history:
Not a know case of diabetes, HTN,asthma, epilepsy, TB, coronary heart disease, thyroid disorders.
Family history:
His father had similar complaints of pain in multiple joints.
Personal history:
The patient consumes mixed diet, no loss of appetite, increased frequency of urination, no burning micturition, regular bowel moments, no addictions.
General examination:
The patient was conscious, coherent and cooperative
He is examined in a well ventilated and aerated room with his full consent
The patient is well built and well nourished
Pallor : ABSENT
Icterus : ABSENT
Clubbing :ABSENT
Cyanosis :absent
Lymphadenopathy: absent
Pedal edema: absent
Vitals:
Pulse: 78bpm
Bp:130/70 mm Hg
Temperature:Afebrile
RR:16 breaths/min
Local examination of left knee joint:
INSPECTION-
Skin is normal
No visible scars, sinus
No redness
No swelling
PALPATION-
Local rise in temperature present
Tenderness present
Range of moments:
Restricted moments.
Patient is unable to perform his daily activities using knees
Systemic examination:
PER ABDOMINAL EXAMINATION:
INSPECTION-
Shape of abdomen : flat
Umbilicus : inverted
All quadrants of abdomen move with respiration
No visible peristalsis, pulsations, sinuses, engorged veins, hernial sites c, no scar on the abdomen
PALPATION-
Abdomen soft
No local rise of temperature
No tenderness
No organomegaly
PERCUSSION:
Resonant note heard over all quadrants.
AUSCULTATION:
Bowel sounds heard
CVS EXAMINATION:
INSPECTION
The chest wall is bilaterally symmetrical
No dilated veins, scars or sinuses are seen
Apical impulse not visible
PALPATION:
Apex beat localised
AUSCULTATION:
S1 and S2 heard
No Murmurs
RESPIRATORY EXAMINATION:
INSPECTION:
Shape of chest: bilaterally symmetrical
Expansion of chest: Equal on both sides
Position of trachea: Central
No visible scars, sinuses, pulsations
PALPATION:
Inspectory findings confirmed
No tenderness, local rise of temperature
Normal expansion of chest on both sides in all areas
Position of trachea: Central
Vocal fremitus: resonant note felt
PERCUSSION:
Resonant note heard over all areas
AUSCULTATION:
Slight wheezing sound is heard
Vocal resonance: resonant in all areas
PROVISIONAL DIAGNOSIS:
Gout